Cardiopulmonary resuscitation algorithm for children. CPR algorithm. Carrying out CPR in children: algorithm. CPR for pregnant women. CPR algorithm for respiratory arrest in adults

G.V. Karpov 1, T.A. Ermolaeva 1, I.S. Reznik 1, V.N. Guba 1, T.A. Malikova 1,
E.V. Malikov 1, L.I. Bryskova 1, Yu.D. Ivashchuk 2

MUZ Clinical Hospital No. 5 g.o. Togliatti (chief physician – candidate of medical sciences N.A. Renz) 1, Russian Federation
Odessa SMP 2, Ukraine

The European Resuscitation Council (ERC) guidelines for cardiopulmonary resuscitation (CPR) are based on the Consensus Statement on Evidence-Based CPR and Treatment Recommendations (CoSTR) developed by the International Committee on Resuscitation (ILCOR). ILCOR was founded in 1992 as an international collaboration committee between the American Heart Association, the ERC, the Cardiovascular Foundation of Canada, the Resuscitation Council of South Africa, the Australian and New Zealand Council and the Latin American CPR Council. The full text of the 2005 ERS CPR manual, as well as the ILCOR СoSTR document, are freely available on the ERC website - www.erc.edu

The evidence base underlying these recommendations is based on 2 studies - retrospective and prospective - which showed an increase in survival from out-of-hospital circulatory arrest if CPR measures were performed before defibrillation. A prospective study demonstrated that if circulatory arrest was delayed by 5 minutes or more, survival at hospital discharge was higher in patients who received CPR before defibrillation. A third study did not confirm positive influence on the survival of first-line CPR, but data from all three studies suggest benefits of this approach.

For many issues there was little or no evidence available, so the guidance was based on expert consensus.

Resuscitation in children is different from resuscitation in adults. The reasons for these differences are primarily related not to the anatomical or physiological differences between adults and children, which are well known to anesthesiologists and resuscitators, but to the pathophysiology of the conditions leading to circulatory arrest. Cardiac arrest in children is rarely due to primary cardinal causes. Much more often it occurs as a result of hypoxemia and shock. By the time circulatory shock develops, irreversible changes caused by conditions preceding circulatory arrest have already developed in the child’s internal organs. As a result, survival rates are generally low. The percentage of survival with a favorable neurological outcome during out-of-hospital circulatory arrest in children varies between 0-12%, but in a hospital setting a higher survival rate is observed (up to 25%). Exceptions to this statement include cases of sudden death syndrome (SDS) in infants, major trauma, or definite primary cardiac arrest.

Resuscitation of children especially early age often they don’t start out of fear of harm, because doctors don’t remember or don’t know the characteristics of the child’s body. The difference in resuscitation techniques in children and adults often prevents not only those around them, but also medical workers from starting first aid - artificial respiration, chest compressions. The new guidelines offer a simpler, unified approach to resuscitation in children and adults. It has been proven that the outcome will be better if at least artificial respiration is attempted, or only chest compressions, than nothing at all.

Causes clinical death in children

There are many fairly common causes of clinical death (CS) in children, but most of them fit into the following classification: respiratory diseases (pneumonia, drowning, smoke inhalation, aspiration and airway obstruction, apnea, suffocation, bronchiolitis, epiglottitis); cardiovascular diseases(congenital heart disease, congestive heart failure, pericarditis, myocarditis, arrhythmias, septic shock); diseases of the central nervous system (seizures and their complications, hydrocephalus and shunt dysfunction, tumors, meningitis, intracranial hemorrhages) and others (trauma, sudden death syndrome, anaphylaxis, gastrointestinal bleeding, poisoning). According to published studies, lesions of the respiratory system, together with SHS, consistently account for one to two thirds of all cases of CS in children.

Clinical death (CS) is the state of the body after circulatory arrest for a period of time, after which restoration of independent cardiac activity is possible.

Diagnosis of CS is made based on the presence of the following signs:

• lack of consciousness and reaction to treatment (mild painful irritation);
• lack of breathing and heartbeat (absence of pulse in large arteries);
• wide pupils;
• cyanosis or pallor;
• total muscle relaxation;
• areflexia.

Diagnosis of clinical death should not take more than 10-15 seconds. Ascertaining the fact of apnea (in combination with lack of consciousness) makes it unnecessary to assess the state of the pulse and requires immediate resuscitation measures.

Cordially- pulmonary resuscitation implies a set of actions aimed at maintaining air exchange and blood circulation in the body by ensuring free passage of the airways, performing artificial ventilation and chest compressions during CS.

Currently, in most countries, the term “resuscitation” has been replaced by “life support”, conditionally dividing activities into basic (basic life support) and advanced (advanced life support). At the same time, basic measures should be started immediately after recognition of the CS condition and do not involve the use of any special devices and devices, while advanced measures must be carried out using special equipment.

A set of equipment, materials and medications for providing resuscitation care should be available around the clock in any department of the hospital, and not just in the intensive care unit. The personnel of any medical unit must have the skills to provide resuscitation benefits, since any delay in providing assistance seriously worsens the prognosis.

The ratio of the frequency of compressions and inflation into the lungs

When carrying out resuscitation measures, the Recommendations provide for maximum continuity of chest compressions. Therefore, it is recommended that non-professional rescuers or those providing assistance alone perform resuscitation as follows: 30 compressions for two inflations (as for adults). However, if assistance is provided by two people or a professional, then 15 compressions should be performed for 2 inflations (inhalation duration 1 second). Although there is no evidence to support the use of a specific frequency in pediatric intensive care, the previously recommended ratio of 5:1 is no longer considered acceptable because does not provide sufficient frequency of compressions.

Age characteristics

With the abolition of differences in the ratio of the frequency of compressions and insufflations when providing care to children and adults, there was no longer a need to divide patients into age groups. Resuscitation measures are as effective for children as they are for adults. The difference lies only in the etiological factor. If it is still necessary to determine which age group the victim belongs to, then the boundary should be drawn at the beginning of adolescence. However, determining age in such conditions seems unnecessary and inappropriate. In this case, the victim should be assisted according to pediatric recommendations. An error in choosing a technique for providing assistance depending on age in this case will not have harmful consequences, since the main reactions develop in the same way in both children and adolescents.

Chest compression technique

The place where pressure should be applied is determined by the xiphoid process (as in adults), and not by the line connecting the nipples, as before. In older children, this point is simply located in the middle of the front surface of the chest (as in adults). Therefore, the difficulties associated with finding the place where compression should take place were eliminated.

The compression technique has also been simplified. It is recommended to compress the chest to half or a third of its normal volume. Compression can be applied with one finger, one hand or two hands to ensure the desired degree of compression. In small children, if two people are assisting, it is recommended to use the compression technique with a circle formed by two thumbs.

The mechanism that causes blood to move during external cardiac massage is actively discussed. The two most popular theories have been proposed: either the effect of direct compression of the heart, or the expulsion of blood from the lungs and left chambers of the heart due to increased intrathoracic pressure (thoracic pump).

Basic Life Support (BLS)

1. Place the patient on a hard surface, tilt his head slightly back. When providing assistance to a patient who has suffered from unknown circumstances, by throwing back the head, one must remember the possibility of damage to the cervical spine. Perform a visual inspection of the respiratory tract for the presence of foreign bodies, vomit, etc.
2. Take two deep expiratory breaths mouth-to-mouth for 1 second. In a medical institution (clinic, emergency department, etc.), this breathing can be performed through a special face mask. The consistency of artificial respiration is assessed during each inspiration by the presence of chest excursion and exhalation. Absence of chest excursion and exhalation indicates ineffective inspiration.
3. After the second inspiration, the presence of a pulse in the central arteries is determined.
4. Absence of pulse, severe bradycardia - indirect cardiac massage.

It is fundamentally important to pay attention to full expansion of the chest when performing compressions. Insufficient chest expansion leads to insufficient diastolic filling and, accordingly, insufficient stroke volume.

The algorithm for basic activities to support life in children is shown in Figure 1.

Advanced Life Support for Children

Advanced activities involve the use various types instrumental manipulations and medications during resuscitation in patients who are in a terminal condition or in a state of clinical death (see Fig. 2).

The PALS (Pediatric Advance Life Support) system includes 6 conditions starting with the letter “N” and 4 conditions starting with the letter “T”.

List of Removable Causes for Mnemonic Memorization

Hypovolemia

Hypovolemia is a reversible cause of cardiac arrest. It can easily be prevented by timely diagnosis. On early stages administration of colloidal solutions does not provide benefits; isotonic saline solutions are recommended. Dextrose solutions are not recommended as they can cause hyponatremia and hyperglycemia, which worsens the neurological outcome of cardiac arrest.

Ways to maintain airway patency

The first attempt to maintain patency of the airway is to restore its correct position. Often this one event has an effect. Since most cases of airway obstruction are caused by gravity acting on the soft tissue mass of the mandible, it can be relieved by extending the head and lifting the chin or using the mandibular advancement technique.

Vomit or other foreign bodies may also block the airway. Examine their lumen for the presence of this obstruction and use the aspirator as early and often as possible.

In some cases, naso- or oropharyngeal airways can be used in patients with an altered level of consciousness. Children with impaired consciousness usually tolerate softer nasopharyngeal airways better than hard, less comfortable oropharyngeal airways. The use of such devices often benefits post-seizure children who continually attempt to breathe spontaneously but have upper airway obstruction due to low muscle tone.

Currently, tracheostomy in children is not routinely used to provide access to the airway in an emergency.

Ways to deliver extra oxygen to your baby

Supplemental oxygen can be delivered to your baby in a variety of ways. The most severely ill patients should be provided with oxygen in the highest concentration and in the most direct manner possible.

Children who maintain spontaneous breathing require less invasive methods providing additional oxygenation. Below are a few in various ways oxygen delivery and the corresponding potential oxygen content in the inhaled air.

Children whose spontaneous respiratory efforts are inadequate require mechanical respiratory support. Different mask methods of ventilation with a breathing bag with a valve are characterized by unequal oxygen delivery capabilities. Self-inflating bag-valve devices are capable of providing a 60-90% oxygen concentration in the inhaled air, while non-inflating devices (anesthesia breathing equipment) provide the patient with 100% oxygen. Endotracheal intubation is the safest and most direct method of delivering 100% oxygen to the patient.

Indications for tracheal intubation

In addition to the most obvious indication for tracheal intubation, ongoing apnea, there are a number of others, including the following:

• Inadequate central regulation of breathing.
• Functional or anatomical airway obstruction.
• Loss of protective airway reflexes.
• Excessive work of the respiratory muscles, which can lead to fatigue and respiratory failure.
• The need to maintain high pressure in the respiratory tract to ensure effective gas exchange in the alveoli.
• The need for hardware respiratory support.
• Potential risk of developing any of the above situations during transport of the patient.

In many cases, the patient is ventilated using a bag through a mask and through an endotracheal tube.
the tube turns out to be equally effective. Under this condition, it is logical to use the method that the anesthesiologist-resuscitator is better at.

Choosing the endotracheal tube size

For intubation, three tubes are prepared: the calculated diameter, one size larger, one size smaller. There are many ways to guarantee right choice endotracheal tube (ETT) size. The most frequently cited formulas are based on the child’s age: less than 6 years – age in years / 3 + 3.75;

• more than 6 years – age in years / 4 + 4.5
• for all ages – (age in years + 18) / 4

Studies have shown that when choosing an endotracheal tube, you can focus on the width of the nail plate of the fifth finger (little finger) of the child, which approximately corresponds to the outer diameter of a correctly selected ETT.

Use uncuffed tubes in all children under 10 years of age; in these patients, the anatomical narrowing at the level of the cricoid cartilage acts as a natural cuff.

The proper depth of insertion of the ETT, taking the patient's anterior incisors as a reference point, can be approximately calculated by multiplying the internal diameter of the tube by 3. Measuring the concentration of CO2 in the exhaled air, observing the symmetry of chest inflation, and auscultation will help ensure the correct position of the ETT breath sounds at both sides. The best way reliably determine the position of the tube, probably radiologically, using a chest x-ray: the proximal end of the ETT should be projected onto the region of the II-III thoracic vertebrae. With nasotracheal intubation, the depth of the tube is 3 cm greater.

Vascular access

First of all, try the method that you personally have the greatest success with.

One small catheter is better than nothing!

These “golden rules” should take no more than 90 seconds.

Remember: During resuscitation, procedures must be performed by those who are best at them, and those people must do what they do best. It is good to have a large diameter vascular access available during resuscitation, although a thin catheter is sufficient for the administration of drugs and slow infusion of fluids.

Currently, it is generally accepted to refuse intracardiac administration of drugs during cardiopulmonary resuscitation, since there is a high probability of severe complications (hemopericardium, pneumothorax, etc.)

Medication provision

Remember: when providing assistance to each child in in serious condition, priority should always be given to oxygenation and ventilation. Drug therapy is intended for those for whom basic measures have not provided sufficient effect.

1. Adrenaline

Behind Lately recommendations for dosing of epinephrine have been the subject of much debate. The reports cited observations of "increasing effectiveness" of high-dose epinephrine during cerebral resuscitation of children who had undergone documented CPR. Other reports have shown no increase in efficacy with increasing doses of epinephrine. While the results of appropriately designed prospective studies are awaited, the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) developed the PALS program, where they published recommendations for the use of epinephrine in cases of asystole. In general, for asystole in children, adrenaline should not be used exactly as it is prescribed to eliminate bradycardia. However, in both situations, the method of titrating the dose of epinephrine as it is administered is used.

• If the first dose to eliminate asystole is administered into the vascular bed (intravenous or intraosseous), use the standard dosage (0.01 mg/kg). This amount of the drug is contained in 0.1 ml/kg of a solution of adrenaline 1: 10,000, i.e. 1 ml of 0.1% adrenaline solution is diluted to 10 ml with saline and 0.1 ml/kg body weight is administered, which corresponds to a dose of 10 mcg/kg (approximately every two-minute loops, starting with heart rate assessment - see Fig. 2) .
• If the first dose to eliminate asystole is administered endotracheally, use a larger amount of the drug (0.1 mg/kg). This dose is contained in 0.1 ml/kg of a 1:1000 adrenaline solution.
• With each repeated administration of epinephrine to combat asystole, high doses should be used (0.1 mg/kg, or 0.1 ml/kg solution diluted 1:1000), regardless of the route of administration.

• For each intravascular (intravenous or intraosseous) administration of epinephrine, a standard dose (0.01 mg/kg) is used, usually in the form of 0.1 ml/kg of a 1:10,000 solution of the drug.
• For each endotracheal insertion, it is used high dose(0.1 mg/kg), which is contained in 0.1 ml/kg of adrenaline solution 1:1000.

There are four drugs traditionally used in resuscitation that remain effective when administered through an endotracheal tube. These are lidocaine, atropine, naloxone and adrenaline. The abbreviation LANE (lidocaine, atropine, naloxone, epinephrine) helps you remember them easily. The drug Versed (midazolam) is also used and effective when administered endotracheally. When you add it to the list, you get another abbreviation: NAVEL.

With the exception of adrenaline, doses of drugs for endotracheal administration are the same as for intravascular administration. In each case, the use of the endotracheal route increases the dose of adrenaline (up to 0.1 mg/kg), the dose of lidocaine - 2-3 mg/kg, the dose of atropine - 0.03 mg/kg, the dose of naloxone should not be lower than 0.1 mg/kg in children under 5 years of age and 2 mg in children over 5 years of age and adults. The drug is diluted in 5 ml of saline and quickly injected into the lumen of the endotracheal tube and then 5 artificial breaths are taken.

2. Atropine

Atropine (usual dose 0.02 mg/kg) has a minimum dose threshold for effective elimination bradycardia. It turns out that in amounts less than 0.1 mg, this drug has an effect that can actually increase bradycardia. Thus, when considering atropine as a treatment for bradycardia in a child who weighs less than 5 kg, the minimum dose to administer is 0.1 mg.

3. Calcium preparations

Although the use of calcium during resuscitation has been abandoned in many cases, there remain special circumstances in which it is of significant value. Use calcium to treat the following documented conditions:

• hypocalcemia (plasma Ca++< 1,0 ммоль/л);
• hyperkalemia;
• hypermagnesemia;
• blocker overdose calcium channels(for example, nifedipine);
• transfusion of large volumes of blood.

When calcium is needed, it should be administered at a slow pace. Rapid infusion results in severe bradycardia. Take care that solutions containing calcium and sodium bicarbonate are not poured one after the other. If these substances mix, they react to form calcium carbonate (chalk), which settles in the internal infusion system. Used in the form of a 10% solution of calcium chloride at a dose of 20 mg/kg (0.2 ml/kg), administered intravenously slowly. You can repeat the dose after 15 minutes, administer twice in total.

4. Sodium bicarbonate

Sodium bicarbonate is a drug that has been used successfully to reverse documented metabolic acidosis. However, it is only effective if there is adequate ventilation. When bicarbonate combines with hydrogen, a complex compound is formed that breaks down into carbon dioxide and water. Carbon dioxide can only be eliminated in one way - through breathing. In the absence of effective ventilation, this byproduct is not eliminated and the buffering effect of bicarbonate is eliminated.

During resuscitation, the ideal pH is 7.3-7.35. Implementation of laboratory control (LLC)
during the resuscitation process, it is possible to make adequate decisions (to administer or not to administer bicarbonate). Its administration should be considered in cases of hyperkalemia or tricyclic antidepressant overdose.

The starting dose of sodium bicarbonate is 1 mmol/kg body weight (1 ml of 4% soda solution contains 0.5 mmol of soda). Subsequent doses are selected based on the CBS parameters (0.3 × BE? MT in kg) or at the rate of 0.5 mmol/kg every 10 minutes. The total dose for resuscitation is 4-5 mmol/kg. It is administered slowly as a bolus (no faster than 2 minutes) or as a drip.

5. Glucose

The only indication for the administration of glucose drugs during cardiopulmonary resuscitation is
is hypoglycemia (glycemia less than 2 mmol/l). The dose is 0.5 g/kg as a 10% or 20% solution
glucose.

6. Lidocaine

Used to relieve ventricular tachycardia and refractory fibrillation. Doses: intravenous or intraosseous 1 mg/kg, with titration - 20-50 mcg/kg/min.

7. Amiodarone

Used for the same indications as lidocaine. Administered at a dose of 5 mg/kg intravenously or intraosseously, subsequent infusion is carried out at a rate of 5-15 mcg/kg/min. The maximum dose per day is 15 mg/kg.

Methods for simple calculation of drug concentrations for continuous infusion

Several are used simple ways:

For a continuous infusion of drug (epinephrine), starting at a rate of 0.1 mcg/kg/min: if 0.6 is multiplied by the patient's body weight in kilograms, this corresponds to the number of milligrams of drug that must be added to a sufficient volume of solution to make the total 100 ml. The resulting solution is then administered at a rate of 1 ml/h, equivalent to a dose of 0.1 μg/kg/min.

Dopamine 4% (calculated daily dose is diluted with saline to 48 ml). The selected dose (mcg/kg/min) of 4% dopamine is successively multiplied by body weight (kg) by 60 (minutes) by 24 (hours) and divided by 40,000:

To 3.6 ml of 4% dopamine, 44.6 ml of saline should be added (up to 48 ml) and administered by perfusion at a rate of 2 ml/h, which is equivalent to the selected dose of 5 mcg/kg/min.

Dobutamine 1% (250 mg diluted in 25 ml of 5% glucose). The selected dose (mcg/kg/min) of 1% dobutamine is successively multiplied by body weight (kg) by 60 (minutes) by 24 (hours) and divided by 10,000:

For example, for a 5-year-old child weighing 20 kg, the calculated dose is 5 mcg/kg/min:

To 14.4 ml of 1% dobutamine you need to add (up to 48 ml) 33.6 ml of 5% glucose and inject it with a perfusor
at a rate of 2 ml/h, which is equivalent to the selected dose of 5 mcg/kg/min.

In terms of the inotropic effect, dobutamine is not inferior to adrenaline and exceeds dopamine. The main benefit of dobutamine is to a lesser extent an increase in oxygen consumption, but to a greater extent increased oxygen delivery to the myocardium.

Electrical defibrillation during resuscitation in children is a relatively rare intervention in the practice of a pediatric anesthesiologist-resuscitator. Asystole is a much more common type of heart rhythm disturbance during circulatory arrest. Fibrillation is not typical for a child's heart. Therefore, the heart rhythm must be carefully assessed before defibrillation is attempted. It is not recommended to defibrillate a child without a monitor. Precordial stroke is also not recommended for use in children.

The mechanism of action of defibrillation is the massive polarization of myocardial cells to stimulate a return to spontaneous sinus rhythm. As soon as ventricular fibrillation is diagnosed, begin to prepare the patient for defibrillation, correct acidosis and hypoxemia. The administration of adrenaline can increase the amplitude of fibrillation waves. In this case, it is necessary to immediately perform electrical defibrillation with a discharge (with a biphasic wave) of 4 J/kg, followed by mechanical ventilation and chest compressions for 2 minutes, then determine the state of cardiac activity using a cardiac monitor.

Shock size recommendations for defibrillation have been revised. Some studies have shown that an initial monophasic or biphasic shock of 2 J/kg is sufficient to terminate ventricular fibrillation. At the same time, studies related to pediatric resuscitation showed that stronger shocks (4 J/kg) also stopped fibrillation with minimal side effects. Therefore, to enhance the impact of the first shock in pediatric practice, when manually setting the shock value, it is recommended to use a level of 4 J/kg. There is still no convincing evidence for or against the use of a defibrillator in children less than a year old.

For electrical defibrillation in children over 1 year old, electrodes with a diameter of 8-12 cm are used, the force is 5 kg for children from 1 to 8 years old, 8 kg for children over 8 years old. It is absolutely necessary to use a special water-based gel, which generously lubricates the surfaces of the electrodes, which are then pressed tightly against the patient’s skin. It is unacceptable to use wipes moistened with various solutions or gel intended for ultrasonic devices for these purposes.

One electrode is placed on the anterior chest wall in the right subclavian region, and the other on lateral surface the left half of the chest along the axillary line. If there are electrodes for adults, one electrode is placed on the back, under the left shoulder blade, and the other to the left of the sternum. During the discharge, it is unacceptable for anyone to touch the patient or the surface on which he is lying. It is also unacceptable for the defibrillator electrodes to touch each other during the discharge.

Even relatively short breaks in cardiac massage outside and inside the hospital are accompanied by a decrease in the likelihood of fibrillation turning into another rhythm disorder and reduce the chances of survival. Previously, when using the triple shock protocol, the time spent defibrillating and analyzing the subsequent rhythm resulted in a delay in continuing CPR. This fact, combined with the increase in the effectiveness of the first shock (for stopping fibrillation and ventricular tachycardia) through the use of a biphasic discharge method, led to the transition to a single shock strategy for defibrillation.

Some mandatory actions after recovery heart rate

• Post-resuscitation administration is the final, but no less important link in the chain of survival. Interventions in the post-resuscitation period are critical to ensuring a favorable outcome. Once stabilization is achieved, the patient is immediately taken to the hospital department where he can be provided with the maximum level of monitoring and treatment.
• Central venous access - a catheter with at least two lumens is required. One lumen is used for administering hemodynamically significant drugs, the second for monitoring central venous pressure, taking tests, and administering scheduled medications.
• Correction of bcc. There is no fundamental difference in the choice of drugs. For the correction of bcc, crystalloid solutions and colloids are equally effective. Do not use glucose solutions. Monitoring central venous pressure is not the only factor reflecting the state of volume, but the dynamics of this indicator against the background of correction of blood volume is important. In addition to circulating blood volume, normal plasma electrolyte levels should be achieved during the first hour(s) after rhythm restoration, with a focus on potassium and ionized calcium levels. Monitoring the effectiveness of BCC correction is ensured by taking biochemical tests according to indications.
• When injecting an inotropic drug, the advantages and disadvantages of inotropic drugs (dopamine, dobutamine, adrenaline) are not discussed in this case, since the correct use of any of them will be effective. It should be taken into account that in the absence of cardiac activity the myocardium experienced ischemia, its recovery was accompanied by a mechanical effect on the heart, and therefore contractility should be reduced. The severity and duration of myocardial failure depends on many circumstances, among which the duration of circulatory arrest, the time of onset and duration of resuscitation are important. The purpose of inotropic drugs is to restore normal cardiac output, coronary and organ perfusion. It should be carried out in a separate lumen of the central venous catheter and necessarily in conditions of at least non-invasive blood pressure monitoring. Direct monitoring of cardiac output (not available in most cases) can be quite successfully replaced by assessing the dynamics of plasma lactate levels and continuous measurement of hemoglobin saturation of venous blood (superior vena cava). Vasopressors are prescribed after resuscitation in conditions of corrected blood volume in the presence of arterial hypotension, which is not eliminated by the administration of an inotropic drug.
• Artificial ventilation. Even complete well-being of the circulatory system, mechanical ventilation parameters close to physiological, as well as restoration of spontaneous breathing immediately after restoration of heart rhythm should not be considered as a reason for extubation. After resuscitation, the patient must be on mechanical ventilation for at least 12-24 hours. In addition, a correct approach to the management of ventilation, oxygenation, and acid-base status requires obtaining arterial blood for testing.
• Seizure prevention and sedation. Due to the high sensitivity of the brain to hypoxemia, cerebral edema is an expected consequence of clinical death. To prevent seizures, it is advisable to use benzodiazepines in standard dosages.
• Correction of thermoregulation. A period of hyperthermia is often observed within 48 hours after circulatory arrest. This usually indicates a poor neurological outcome. Hyperthermia should be treated aggressively with antipyretics and general cooling in the first 72 hours after cardiac arrest. It is believed that moderate therapeutic hypothermia may have a beneficial effect in the post-resuscitation period. For a patient whose circulation has been restored after cardiac arrest but is still unconscious, cooling to a temperature of 32-34°C for 12-24 hours may be beneficial. After this period of moderate hypothermia, the child should be slowly (0.25-0.5°C per hour) warmed to normal temperature.
• Blood sugar control. There is a clear relationship between high glycemic levels and poor neurological outcome. Careful correction of blood sugar (4.4-6.1 mmol/l) with insulin can reduce hospital mortality after circulatory arrest.
• Presence of parents (preferred, but not required). Research has shown that it is better for family members to be present with a child who has suffered cardiac arrest, as this gives them the opportunity to evaluate resuscitation efforts and their outcome. Parents in this case experience less deep depression in the coming months after the death of the child. There should be a health worker nearby who can explain the essence and purpose of the measures. Relatives should not interfere with the resuscitation process or disturb members of the resuscitation team. It is not the parents, but the senior doctor of the team with the other members who should evaluate the advisability of further resuscitation.

Carrying out cardiopulmonary resuscitation requires reflection in the CPR protocol, which, in addition to passport data, must contain information about the time and probable cause of circulatory arrest, time of tracheal intubation, time of administration and dosages of drugs, time and energy of defibrillation, time of restoration of heart rhythm and be signed by all participants in the resuscitation.

Contraindications to resuscitation

Contraindications to resuscitation are considered in accordance with state legislation:

1. Instructions for determining the criteria and procedure for determining the moment of death of a person and terminating resuscitation measures.
2. Instructions for declaring a person's death based on brain death. Scrupulous implementation of each point of this instruction when establishing a diagnosis of brain death practically guarantees the protection of the anesthesiologist-resuscitator from mistakes.
3. Fundamentals of legislation Russian Federation on protecting the health of citizens (dated July 22, 1993 No. 5487-1).

Resuscitation measures are not carried out in the following cases:

• lack of blood circulation in conditions of normothermia for more than 10 minutes, as well as in the presence external signs biological death (hypostatic spots, rigor mortis);
• injury incompatible with life;
• birth defects developments incompatible with life;
• terminal stages of long-term incurable diseases and AIDS patients;
• diseases of the central nervous system with profound intellectual deficit.

Remember that due to difficulties in distinguishing between reversible and irreversible conditions, resuscitation aid should be started in all cases of sudden (sudden) death and should be clarified prognostically as resuscitation progresses significant features anamnesis. The decision “do not resuscitate”, refusal of resuscitation measures due to their potential ineffectiveness in patients with terminal stages of chronic diseases, is advisable to formalize as a decision of the council in advance.

Resuscitation measures should continue until spontaneous circulation is restored or signs of death appear. The death of the heart becomes obvious in the case of development of persistent (according to at least, for 30 minutes) electrical asystole (straight line on the ECG). Mechanical asystole without electrical (there is no pulse, and the ECG shows a curve of the electrical potentials of the heart) is not a sign of irreversibility. As long as ECG activity persists, one should not lose hope of restoring spontaneous circulation.

Brain death is a complete and irreversible disruption of brain function while blood circulation in the rest of the body is still maintained. Prerequisites for making a diagnosis of brain death:

• lack of consciousness (profound coma);
• absence of spontaneous breathing (ascertained after a test with apneic oxygenation for 3-10 minutes and monitoring the partial tension of CO 2 in arterial blood);
• non-responsive to light, fixed, moderately or maximally dilated pupil (without the effect of mydriatics);
• absence of oculocephalic, corneal, pharyngeal, laryngotracheal, oculo-vestibular, gag, cough reflexes;
• lack of response to painful stimuli in the area of ​​the trigeminal nerve, i.e. there is inhibition of all reactions to external stimuli.

It is possible to document brain death in a patient who meets the above criteria in the absence of hypothermia, arterial hypotension, and in case of refusal to use drugs from muscle relaxants, hypnotics, or opioids for at least 24 hours before performing tests.

Additional examinations: an isoelectric line on an EEG for 30 minutes in combination with the above symptoms is enough to diagnose brain death without further observation. Without encephalography, these symptoms should be noted:

• in case of primary brain damage – within 12 hours;
• with secondary brain damage within 3 days.

Only after these intervals can a diagnosis of “brain death” be made. In infants and children of the first years of life, all cases of primary brain damage should be observed within 24 hours. The criteria for brain death vary slightly in different countries depending on the legislation regarding organ transplantation.

It should be noted that the degree of brain damage during resuscitation cannot be determined. Therefore, only irreversible cardiac arrest is a prerequisite for making a decision to stop resuscitation. Only the doctor is responsible for this decision! There are no clear recommendations or rules governing the termination of resuscitation. A successful result largely depends on the initial condition of the patient. The longer resuscitation continues, the less chance of success, but this situation is not absolute!

If blood circulation is not restored within 30-40 minutes of active resuscitation, resuscitation measures can be stopped and biological brain death can be declared.

There are a number of exceptions when resuscitation measures need to be continued for more than 30 minutes:

• pediatric resuscitation;
• hypothermia (it is impossible to declare death until it is completely warmed to room temperature);
• drowning (especially in cold water);
• repeatedly recurrent ventricular fibrillation.

Typical mistakes during CPR. During resuscitation, the cost of any tactical and technical errors is high, so it is advisable to dwell on the typical ones.

Tactical mistakes:

1. delay in starting cardiopulmonary resuscitation, loss of time on secondary diagnostic, organizational and treatment procedures, premature cessation of resuscitation measures;
2. lack of clear accounting of activities carried out therapeutic measures, monitoring the implementation of assignments, time control;
3. the absence of one manager, the participation of several specialists giving different orders, the presence of unauthorized persons;
4. lack of constant monitoring of the effectiveness of cardiopulmonary resuscitation;
5. weakening of control over the patient after restoration of blood circulation and breathing, insufficient attention to secondary prevention ventricular fibrillation;
6. overestimation of CBS disorders, uncontrolled administration of bicarbonate after short-term clinical death or in case of insufficiently effective mechanical ventilation.

Errors in cardiac compression:

1. the patient lies on a soft base, a springy surface;
2. incorrect positioning of the anesthesiologist-resuscitator's hands on the victim's chest;
3. the anesthesiologist-resuscitator lifts his arms from the chest and bends them in elbow joints;
4. breaks in compression are allowed for no more than 10 s (for defibrillation, evaluation of effectiveness);
5. the frequency of compressions is disrupted.

Errors during ventilation:

1. free airway patency is not ensured;
2. tightness during breathing is not ensured;
3. underestimation (unsatisfactory quality) or overestimation (start of CPR with intubation) of mechanical ventilation;
4. lack of control over chest excursions;
5. lack of control over air entering the stomach;
6. attempts at drug stimulation of breathing.

Defibrillation errors:

1. the gaskets under the electrodes are poorly wetted;
2. the electrodes are not pressed sufficiently to the chest wall;
3. insufficient charge energy;
4. repetition of the shock immediately after the administration of drugs, with cessation of cardiac compression for 1-2 minutes;
5. using a technically faulty defibrillator;
6. failure to comply with safety regulations.

Literature

1. Current problems of anesthesiology and resuscitation (issue 14), ed. prof. E.V. Nedashkovsky, Arkhangelsk, 2009. - 386 p.
2. Current problems of anesthesiology and resuscitation (issue 13), ed. prof. E.V. Nedashkovsky, Arkhangelsk, 2008. - 420 p.
3. Current problems of anesthesiology and resuscitation (issue 12), ed. prof. E.V. Nedashkovsky, Arkhangelsk, 2006. - 390 p.
4. Anesthesiology and intensive care in pediatrics, ed. acad. RAMS, prof. V.A. Mikhelson, prof. V.A.Grebennikova, M., 2010. - 402 p.
5. Anesthesiology and intensive care: A practical guide / Ed. Corresponding member RAMS prof. B.R. Gelfand. – 2nd ed., rev. and additional – M.: Litera, 2010. - 484 p.
6. Anesthesia and intensive care in children / V.V. Kurek, A.E. Kulagin, D.A. Furmanchuk. M., 2010. - 470 p.
7. Emergency pediatrics / V.I. Gordeev, Yu.S. Aleksandrovich et al., St. Petersburg, 2003. - 326 p.
8. Rational pharmacoanesthesiology: Director. for practicing doctors / A.A. Bunyatyan, V.M. Mizikov, G.V. Babalyan, E.O. Borisova and others; Under general ed. A.A. Bunyatyan, V.M. Mizikova. – M.: Litera, 2006. - 684 p.
9. Secrets of Emergency Pediatrics / Stephen M. Selbst, Kate Cronan; lane from English; Under general ed. prof. N.P. Shabalova. – M.: MEDpress-inform, 2006. - 412 p.
10. European Resuscitation Council guidelines 2005/ Resuscitation (2005). Resuscitation (2005) 67S1, P. 39-86
11. Order of the Ministry of Health of the Russian Federation No. 73 dated March 4, 2003
12. Order of the Ministry of Health of the Russian Federation and the Russian Academy of Medical Sciences No. 460 dated December 20, 2001. registered by the Ministry of Justice of the Russian Federation on January 17, 2002 No. 3170.
13. International Liaison Committee on Resuscitation. Consensus on Science and Treatment Recommendations. Resuscitation (2005). PEDIATRICS Vol. 117 No. 5 May 2006, pp. 955-977.
14. Kuisma M, Suominen P, Korpela R (1995) Paediatric out-of-hospital cardiac arrests - epidemiology and outcome. Resuscitation 30:141–150.
15. Schindler MB, Bohn D, Cox PN, et al: Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996. 335:1473-1479.

For children under 1 year old, it is enough to press on the sternum with one or two fingers. To do this, lay the child on his back and embrace the child so that the thumbs are located on the front surface of the chest and their ends converge at a point located 1 cm below the nipple line, place the remaining fingers under the back. For children over 1 year of age and under 7 years of age, heart massage is performed standing on the side (usually on the right), with the base of one hand, and for older children - with both hands (like adults).

Ensure airway patency.

Perform tracheal intubation, but only after the first breaths of mechanical ventilation; time should not be wasted on attempting intubation (at this time the patient does not breathe for more than 20 seconds).

During inhalation, the chest and stomach should rise. To determine the depth of inspiration, one should focus on the maximum excursion of the patient’s chest and abdomen and the appearance of resistance to inhalation.

Pause between breaths 2 s.

Inhalation is normal, not forced. Features of mechanical ventilation depending on the age of the child.

The victim is a child under one year old:

It is necessary to cover the child’s mouth and nose with your mouth;

the tidal volume should be equal to the volume of the cheeks;

when performing mechanical ventilation using an Ambu bag, a special Ambu bag is used for children under one year of age;

When using an Ambu bag for adults, the volume of one breath is equal to the volume of the doctor’s hand.

The victim is a child over one year old:

You should pinch the victim’s nose and breathe mouth to mouth;

It is necessary to take two test breaths;

Assess the patient's condition.

Attention: If there are injuries to the mouth, you can use mouth-to-nose breathing: the mouth is closed, the rescuer’s lips are pressed around the victim’s nose. However, the effectiveness of this method is much lower than mouth-to-mouth breathing.

Caution: When performing mouth-to-mouth ventilation (mouth-to-mouth and nose-to-nose, mouth-to-nose), do not breathe deeply or frequently, otherwise you will not be able to ventilate.

Breathe as fast as possible, as close to the recommended rate as possible, depending on the patient’s age.

Up to 1 year 40-36 per minute

1-7 years 36-24 per minute

Over 8 years old, adult 24-20 per minute

DEFIBRILLATION

Defibrillation is performed in case of ventricular fibrillation in the mode of 2 J/kg for the first shock, 3 J/kg for the second discharge, 3.5 J/kg for the third and all subsequent shocks.

The algorithm for drug administration and defibrillation is the same as for adult patients.

COMMON ERRORS

Performing precordial beats.

Carrying out chest compressions in the presence of a pulse in the carotid artery.

Placing any objects under the shoulders.

Applying palm pressure on the sternum in a position to thumb was directed to the resuscitator.

METHOD OF APPLICATION AND DOSES OF MEDICINES

There are two optimal ways to perform cardiopulmonary resuscitation:

intravenous;

intratracheal (through an endotracheal tube or puncture of the cricoid membrane).

Attention: When administering drugs intratracheally, the dose is doubled and the drugs, if they have not been diluted earlier, are diluted in 1-2 ml of sodium chloride solution. Total administered drugs can reach 20-30 ml.

CLINICAL PHARMACOLOGY OF DRUGS

Atropine during resuscitation in children is used in case of asystole and bradycardia at a dose of 0.01 mg/kg (0.1 ml/kg) diluted with 1 ml of 0.1% solution in 10 ml of sodium chloride solution (in 1 ml solution 0.1 mg of the drug). In the absence of information on body weight, it is possible to use a dose of 0.1 ml of 0.1% solution per year of life or at the indicated dilution of 1 ml/year. Administration may be repeated every 3-5 minutes until a total dose of 0.04 mg/kg is achieved.

Epinephrine is used in cases of asystole, ventricular fibrillation, electromechanical dissociation. The dose is 0.01 mg/kg or 0.1 ml/kg when diluted with 1 ml of 0.1% epinephrine solution in 10 ml of sodium chloride solution (0.1 mg of the drug in 1 ml of solution). In the absence of information on body weight, it is possible to use a dose of 0.1 ml of 0.1% solution per year of life or at the indicated dilution of 1 ml/year. Administration can be repeated every 1-3 minutes. If cardiopulmonary resuscitation is ineffective

within 10-15 minutes it is possible to use doses of epinephrine increased by 2 times.

Lidocaine is used in case of ventricular fibrillation at a dose of 1 mg/kg 10% solution.

Sodium bicarbonate 4% is used in cases where cardiopulmonary resuscitation is started later than 10-15 minutes after cardiac arrest, or in case of prolonged ineffective cardiopulmonary resuscitation (more than 20 minutes without effect with adequate ventilation of the lungs). Dose 2 ml/kg body weight.

Post-resuscitation drug therapy should be aimed at maintaining stable hemodynamics and protecting the central nervous system from hypoxic damage (antihypoxants)

In newborns, massage is performed in the lower third of the sternum, with one index finger at the level of the nipples. Frequency - 120 per minute. Inhalations are carried out according to the general rules, but with the volume of the cheek space (25-30 ml of air).

In children under 1 year of age, clasp the chest with both hands and press the front of the sternum with your thumbs, 1 cm below the nipples. The depth of compression should be equal to 1/3 of the height of the chest (1.5-2 cm). Frequency - 120 per minute. Inhalations are carried out according to general rules.

In children under 8 years of age, massage is performed on a hard surface with one hand in the lower half of the sternum to a depth of up to 1/3 of the height of the chest (2-3 cm) with a frequency of 120 per minute. Inhalations are carried out according to general rules.

The CPR cycle in all cases consists of alternating 30 compressions with 2 breaths.

1. Features of CPR in various situations

Features of CPR for drowning.

Drowning is a type of mechanical asphyxia resulting from water entering the respiratory tract.

Necessary:

observing personal safety measures, remove the victim from under the water;

clean the oral cavity of foreign bodies (algae, mucus, vomit);

during evacuation to the shore, holding the victim’s head above the water, perform artificial respiration according to the general rules of cardiopulmonary resuscitation using the “mouth to mouth” or “mouth to nose” method (depending on the experience of the rescuer);

on the shore, call an ambulance to prevent complications that arise after drowning as a result of water, sand, silt, vomit, etc. entering the lungs;

warm the victim and monitor him until the ambulance arrives;

in case of clinical death - cardiopulmonary resuscitation.

Features of CPR in case of electric shock.

If you suspect that a person has been exposed to electric current, be sure to:

compliance with personal safety measures;

stopping the impact of current on a person;

calling emergency services and monitoring the victim;

in the absence of consciousness, place in a stable lateral position;

in case of clinical death - perform cardiopulmonary resuscitation.

1. Foreign bodies in the respiratory tract

The entry of foreign bodies into the upper respiratory tract causes a violation of their patency for oxygen to enter the lungs - acute respiratory failure. Depending on the size of the foreign body, obstruction may be partial or complete.

Partial airway obstruction– the patient breathes with difficulty, his voice is hoarse, he coughs.

call emergency services;

execute first Heimlich maneuver(if cough is ineffective): folded palm right hand Apply several intense blows between the shoulder blades with a “boat”.

Complete obstruction of the airway– the victim cannot speak, breathe, cough, the skin quickly becomes bluish. Without assistance, he will lose consciousness and cardiac arrest will occur.

First aid:

if the victim is conscious, perform second Heimlich maneuver– standing from behind, grab the victim, clasp your hands in a lock epigastric region abdomen and perform 5 sharp compressions (pushes) with the ends of the fists from bottom to top and front to back under the diaphragm;

if the victim is unconscious or there is no effect from previous actions, perform third Heimlich maneuver - lay the victim on his back, apply 2-3 sharp pushes (not blows!) with the palmar surface of the hand in the epigastric region of the abdomen from bottom to top and from front to back under the diaphragm;

In pregnant and obese people, the second and third Heimlich maneuvers are performed in the area of ​​the lower 1/3 of the sternum (in the same place where chest compressions are performed).

Breathing and normal heart function are functions that, when stopped, life leaves our body within a few minutes. First, a person falls into a state of clinical death, soon followed by biological death. Stopping breathing and heartbeat has a strong impact on the brain tissue.

Metabolic processes in brain tissue are so intense that the lack of oxygen is detrimental to them.

At the stage of clinical death, it is quite possible to save a person if you begin to provide first emergency aid correctly and promptly. A set of methods aimed at restoring breathing and heart function is called cardiopulmonary resuscitation. There is a clear algorithm for carrying out such rescue operations, which should be applied directly at the scene of the incident. One of the latest and most full recommendations regarding actions in case of respiratory and cardiac arrest is a manual released by the American Heart Association in 2015.

Cardiopulmonary resuscitation in children is not much different from similar activities for adults, but there are nuances that you should know. Cardiac and respiratory arrest often occurs in newborns.

A little physiology

Once breathing or heartbeat stops, oxygen stops flowing to the tissues of our body, which causes their death. The more complex the tissue is, the more intense the metabolic processes take place in it, the more destructive the effect of oxygen starvation is on it.

The brain tissues suffer the most; a few minutes after the oxygen supply is cut off, irreversible structural changes begin in them, which lead to biological death.

Cessation of breathing leads to disruption of the energy metabolism of neurons and ends in cerebral edema. Nerve cells begin to die approximately five minutes after this, it is during this period that the victim needs to be helped.

It should be noted that clinical death in children very rarely occurs due to problems with the heart; much more often this occurs due to respiratory arrest. This important difference determines the characteristics of cardiopulmonary resuscitation in children. In children, cardiac arrest is usually the final stage irreversible changes in the body and is caused by the extinction of its physiological functions.

First aid algorithm

The algorithm for carrying out first aid in case of cardiac and respiratory arrest in children is not much different from similar measures for adults. Resuscitation of children also consists of three stages, which were first clearly formulated by the Austrian physician Pierre Safari in 1984. After this point, the first aid rules were repeatedly supplemented; there are basic recommendations issued in 2010, and there are later ones prepared in 2015 by the American Heart Association. The 2015 guide is considered the most complete and detailed.

Techniques for providing assistance in such situations are often called the “ABC rule.” Here are the main stages of action in accordance with this rule:

1. Air way oren. It is necessary to free the victim's airways from obstacles that could prevent air from entering the lungs (this point is translated as “open the way for air”). Vomit, foreign bodies, or a sunken root of the tongue can act as an obstacle.
2. Breath for victim. This point means that the victim needs to be given artificial respiration (translated: “breathing for the victim”).
3. Circulation his blood. The last point is heart massage (“circulation of its blood”).

When resuscitating children, special attention should be paid to the first two points (A and B), since primary cardiac arrest is quite rare in them.

Signs of clinical death

You should know the signs of clinical death, which is usually when cardiopulmonary resuscitation is performed. In addition to cardiac and respiratory arrest, it also causes dilation of the pupils, as well as loss of consciousness and areflexia.

Stopping the heart can be detected very easily by checking the victim's pulse. This is best done on the carotid arteries. The presence or absence of breathing can be determined visually, or by placing your palm on the victim’s chest.

After cessation of blood circulation, loss of consciousness occurs within fifteen seconds. To make sure of this, turn to the victim and shake his shoulder.

Carrying out first aid

Resuscitation measures should begin with clearing the airways. To do this, the child needs to be placed on his side. Use a finger wrapped in a handkerchief or napkin to clean the mouth and throat. The foreign body can be removed by tapping the victim on the back.

Another way is the Heimlich maneuver. It is necessary to clasp the victim’s torso with your hands under the costal arch and sharply squeeze the lower part of the chest.

After clearing the airways, artificial ventilation should begin. To do this, it is necessary to extend the victim’s lower jaw and open his mouth.

The most common method of artificial ventilation is the mouth-to-mouth method. You can blow air into the victim’s nose, but it is much more difficult to clean it than the oral cavity.

Then you need to close the victim’s nose and breathe air into his mouth. The frequency of artificial breaths must correspond to physiological standards: for newborns this is approximately 40 breaths per minute, and for children aged five years – 24-25 breaths. You can place a napkin or handkerchief over the victim's mouth. Artificial ventilation helps to activate your own respiratory center.

The last type of manipulation that is performed during cardiopulmonary resuscitation is chest compressions. Heart failure is more often the cause of clinical death in adults; it is less common in children. But in any case, during the provision of assistance, you must ensure at least minimal blood circulation.

Before starting this procedure, place the victim on a hard surface. His legs should be slightly elevated (about 60 degrees).

Then you should begin to strongly and energetically compress the victim’s chest in the sternum area. The point for applying force in infants is right in the middle of the sternum, in older children it is just below the center. When massaging newborns, the point should be pressed with the tips of your fingers (two or three), for children from one to eight years old with the palm of one hand, for older ones - with both palms at the same time.

It is clear that it is extremely difficult for one person to do both processes simultaneously. Before you begin resuscitation, you need to call someone for help. In this case, everyone takes on one of the above tasks.

Try to time the time the child spent unconscious. This information will then be useful to doctors.

Previously, it was believed that 4-5 chest compressions were needed per breath. However, now experts believe that this is not enough. If you perform resuscitation alone, you are unlikely to be able to provide the required frequency of breaths and compressions.

If a pulse appears and spontaneous breathing movements of the victim appear, resuscitation measures should be stopped.

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Features of cardiopulmonary resuscitation in children

He who saved one life saved the whole world

Mishnah Sanhedrin

Features of cardiopulmonary resuscitation in children of different ages, recommended by the European Council on Resuscitation, were published in November 2005 in three foreign journals: Resuscitation, Circulation and Pediatrics.

The sequence of resuscitation measures in children is generally similar to that in adults, but when carrying out life-sustaining measures in children (ABC), special attention is paid to points A and B. If resuscitation of adults is based on the fact of primary heart failure, then a child in cardiac arrest - this is the finale of the process of gradual extinction of the physiological functions of the body, initiated, as a rule, respiratory failure. Primary cardiac arrest is very rare, with ventricular fibrillation and tachycardia being the cause in less than 15% of cases. Many children have a relatively long “pre-rest” phase, which determines the need early diagnosis this phase.

Pediatric resuscitation consists of two stages, which are presented in the form of algorithmic diagrams (Fig. 1, 2).

Restoring airway patency (AP) in patients with loss of consciousness is aimed at reducing obstruction, a common cause of which is tongue retraction. If the muscle tone of the lower jaw is sufficient, then throwing back the head will cause the lower jaw to move forward and open the airway (Fig. 3).

In the absence of sufficient tone, throwing back the head must be combined with moving the lower jaw forward (Fig. 4).

However, in infants there are peculiarities of performing these manipulations:

• Do not tilt the child’s head back excessively;
• should not be squeezed soft fabrics chin, as this may cause airway obstruction.

After clearing the airways, it is necessary to check how effectively the patient is breathing: you need to look closely, listen, and observe the movements of his chest and abdomen. Often, restoring and maintaining the airway is sufficient for the patient to continue breathing effectively.

The peculiarity of artificial pulmonary ventilation in young children is determined by the fact that the small diameter of the child’s respiratory tract provides great resistance to the flow of inhaled air. To minimize the increase in airway pressure and prevent gastric overdistension, inhalations should be slow, and the frequency of respiratory cycles should be determined by age (Table 1).

A sufficient volume of each breath is a volume that provides adequate chest movement.

Make sure that breathing is adequate, there is a cough, movements, and pulse. If there are signs of circulation, continue respiratory support; if there is no circulation, begin chest compressions.

In children under one year of age, the person providing assistance tightly and hermetically grasps the child’s nose and mouth with his mouth (Fig. 5)

in older children, the resuscitator first pinches the patient’s nose with two fingers and covers his mouth with his mouth (Fig. 6).

In pediatric practice, cardiac arrest is usually secondary to airway obstruction, which is most often caused by a foreign body, infection, or allergic process leading to airway swelling. Very important differential diagnosis between airway obstruction caused by a foreign body and infection. In the setting of infection, the act of removing a foreign body is dangerous because it may lead to unnecessary delay in transport and treatment of the patient. In patients without cyanosis and with adequate ventilation, cough should be stimulated; artificial respiration should not be used.

The method of eliminating airway obstruction caused by a foreign body depends on the age of the child. Blind cleaning of the upper respiratory tract with a finger is not recommended in children, since at this moment the foreign body can be pushed deeper. If the foreign body is visible, it can be removed using a Kelly forceps or Medgil forceps. Pressing on the abdomen is not recommended for children under one year of age, since there is a risk of damage to the abdominal organs, especially the liver. A child at this age can be helped by holding him on his arm in the “rider” position with his head lowered below his body (Fig. 7).

The baby's head is supported with a hand around the lower jaw and chest. Four blows are given quickly to the back between the shoulder blades. proximal part palms. Then the child is placed on his back so that the victim’s head is lower than the body during the entire procedure and four pressures are applied to the chest. If the child is too large to be placed on the forearm, he is placed on the hip so that the head is lower than the body. After clearing the airways and restoring their free patency in the absence of spontaneous breathing, artificial ventilation is started. In older children or adults with airway obstruction by a foreign body, it is recommended to use the Heimlich maneuver - a series of subdiaphragmatic pressures (Fig. 8).

Emergency cricothyroidotomy is an option for maintaining airway patency in patients who cannot be intubated.

As soon as the airways are cleared and two test breathing movements are performed, it is necessary to determine whether the child had only respiratory arrest or whether there was cardiac arrest at the same time - the pulse in the large arteries is determined.

In children under one year of age, the pulse is assessed at the brachial artery (Fig. 9)

Because the baby’s short and wide neck makes it difficult to quickly find the carotid artery.

In older children, as in adults, the pulse is assessed at the carotid artery (Fig. 10).

When a child has a pulse, but there is no effective ventilation, only artificial respiration is performed. The absence of a pulse is an indication for performing artificial circulation using closed heart massage. Indoor massage Cardiac surgery should never be performed without artificial ventilation.

The recommended area of ​​chest compression in newborns and infants is a finger's width below the intersection of the nipple line and the sternum. In children under one year old, two methods of performing closed cardiac massage are used:

– location of two or three fingers on the chest (Fig. 11);

– covering the child’s chest with the formation of a rigid surface of four fingers on the back and using thumbs to perform compressions.

The amplitude of compression is approximately 1/3-1/2 of the anteroposterior size of the child’s chest (Table 2).

If the child’s thumb and three fingers do not create adequate compression, then the proximal part should be used to perform closed cardiac massage. palmar surface hands of one or two hands (Fig. 12).

The speed of compressions and their ratio to breathing depends on the age of the child (see Table 2).

Mechanical chest compression devices have been used extensively in adults, but not in children due to the very high incidence of complications.

Precordial shock should never be used in pediatric practice. In older children and adults, it is considered an optional procedure when the patient does not have a pulse and a defibrillator cannot be used quickly.

Read other articles on helping children in various situations

medspecial.ru

Algorithm of actions for cardiopulmonary resuscitation in children, its purpose and types

Restoring the normal functioning of the circulatory system and maintaining air exchange in the lungs is the primary goal of cardiopulmonary resuscitation. Timely resuscitation measures help avoid the death of neurons in the brain and myocardium until blood circulation is restored and breathing becomes independent. Circulatory arrest in a child due to a cardiac cause occurs extremely rarely.

For infants and newborns, the following causes of cardiac arrest are distinguished: suffocation, SIDS - sudden infant death syndrome, when an autopsy cannot determine the cause of cessation of vital activity, pneumonia, bronchospasm, drowning, sepsis, neurological diseases. In children after twelve months, death most often occurs due to various injuries, suffocation due to illness or foreign body entering the respiratory tract, burns, gunshot wounds, and drowning.

Purpose of CPR in children

Doctors divide young patients into three groups. The algorithm for resuscitation is different for them.

1. Sudden stoppage of blood circulation in a child. Clinical death throughout the entire period of resuscitation. Three main outcomes:

• CPR ended with a positive result. At the same time, it is impossible to predict what the patient’s condition will be after his clinical death, and how much the functioning of the body will be restored. The so-called post-resuscitation illness develops.
• The patient lacks the possibility of spontaneous mental activity, and brain cells die.
• Resuscitation does not bring a positive result; doctors declare the patient’s death.

1. The prognosis is unfavorable when performing cardiopulmonary resuscitation in children with severe trauma, in a state of shock, and purulent-septic complications.
2. Resuscitation of a patient with oncology, abnormal development of internal organs, or severe injuries is carefully planned whenever possible. Immediately proceed to resuscitation efforts in the absence of pulse and breathing. Initially, it is necessary to understand whether the child is conscious. This can be done by shouting or lightly shaking, while avoiding sudden movements of the patient’s head.

Primary resuscitation

CPR in a child includes three stages, which are also called ABC - Air, Breath, Circulation:

• Air way open. The airway must be cleared. Vomiting, tongue retraction, foreign body may be an obstacle to breathing.
• Breath for victim. Carrying out artificial respiration measures.
• Circulation his blood. Closed heart massage.

When performing cardiopulmonary resuscitation on a newborn baby, the first two points are most important. Primary cardiac arrest is uncommon in young patients.

Maintaining a child's airway

The first stage is considered the most important in the process of CPR in children. The algorithm of actions is as follows.

The patient is placed on his back, with the neck, head and chest in the same plane. If there is no skull injury, you need to tilt your head back. If the victim has an injury to the head or upper cervical region, it is necessary to move the lower jaw forward. If you are losing blood, it is recommended to elevate your legs. Violation of the free flow of air through the respiratory tract in an infant may increase with excessive bending of the neck.

The reason for the ineffectiveness of pulmonary ventilation measures may be the incorrect position of the child’s head relative to the body.

If there are foreign objects in the oral cavity that make breathing difficult, they must be removed. If possible, tracheal intubation is performed and an airway is inserted. If it is impossible to intubate the patient, breathing “mouth to mouth” and “mouth to nose and mouth” is performed.

Solving the problem of the patient's head tilting is one of the primary tasks of CPR.

Airway obstruction causes the patient's heart to stop. This phenomenon is caused by allergies, inflammatory infectious diseases, foreign objects in the mouth, throat or trachea, vomit, blood clots, mucus, and a child’s sunken tongue.

Algorithm of actions for mechanical ventilation

When performing artificial ventilation, it is optimal to use an air duct or a face mask. If it is not possible to use these methods, an alternative course of action is to actively blow air into the patient’s nose and mouth.

To prevent the stomach from distending, it is necessary to ensure that there is no excursion of the peritoneum. Only the volume of the chest should decrease in the intervals between exhalation and inhalation when carrying out measures to restore breathing.

When carrying out the procedure of artificial ventilation of the lungs, the following steps are carried out. The patient is placed on a hard flat surface. The head is slightly thrown back. Observe the child's breathing for five seconds. If there is no breathing, take two breaths lasting one and a half to two seconds. After this, wait a few seconds for the air to escape.

When resuscitating a child, you should inhale air very carefully. Careless actions can cause rupture of lung tissue. Cardiopulmonary resuscitation of a newborn and infant is carried out using the cheeks to blow air. After the second inhalation of air and its exit from the lungs, the heartbeat is felt.

Air is blown into the child's lungs eight to twelve times per minute at intervals of five to six seconds, provided that the heart is functioning. If a heartbeat is not detected, proceed to chest compressions and other life-saving actions.

It is necessary to carefully check for the presence of foreign objects in the oral cavity and upper section respiratory tract. This kind of obstruction will prevent air from entering the lungs.

The sequence of actions is as follows:

• The victim is placed on the arm bent at the elbow, the baby’s torso is above the level of the head, which is held by the lower jaw with both hands.
• After the patient is placed in the correct position, five gentle blows are applied between the patient's shoulder blades. The blows should have a directed effect from the shoulder blades to the head.

If the child cannot be placed in the correct position on the forearm, then the thigh and bent leg of the person resuscitating the child are used as support.

Closed heart massage and chest compression

Closed cardiac muscle massage is used to normalize hemodynamics. Not carried out without the use of mechanical ventilation. Due to an increase in intrathoracic pressure, blood is released from the lungs into the circulatory system. The maximum air pressure in a child's lungs occurs in the lower third of the chest.

The first compression should be a test, it is carried out to determine the elasticity and resistance of the chest. The chest is squeezed during cardiac massage by 1/3 of its size. Chest compression is performed differently for different age groups patients. It is carried out by applying pressure to the base of the palms.

Features of cardiopulmonary resuscitation in children

The peculiarities of cardiopulmonary resuscitation in children are that it is necessary to use fingers or one palm to perform compression due to the small size of the patients and fragile physique.

• For infants, pressure is applied to the chest using only the thumbs.
• For children from 12 months to eight years old, massage is performed with one hand.
• For patients over eight years of age, both palms are placed on the chest. as for adults, but the force of pressure is proportional to the size of the body. The elbows of the hands remain straight during cardiac massage.

There are some differences in CPR of a cardiac nature in patients over 18 years of age and cardiopulmonary failure resulting from suffocation in children, therefore resuscitators are recommended to use a special pediatric algorithm.

Compression-ventilation ratio

If only one physician is involved in resuscitation, he should perform two air injections into the patient's lungs for every thirty compressions. If two resuscitators are working simultaneously, compression is performed 15 times for every 2 air injections. When using a special tube for ventilation, non-stop cardiac massage is performed. The ventilation rate ranges from eight to twelve beats per minute.

A heart blow or precordial blow is not used in children - the chest may be seriously damaged.

The compression frequency ranges from one hundred to one hundred and twenty beats per minute. If the massage is performed on a child under 1 month old, then you should start with sixty beats per minute.

Resuscitation efforts should not be interrupted for more than five seconds. 60 seconds after resuscitation begins, the physician should check the patient's pulse. After this, the heartbeat is checked every two to three minutes when the massage stops for 5 seconds. The state of the pupils of the person being resuscitated indicates his condition. The appearance of a reaction to light indicates that the brain is recovering. Persistent dilation of the pupils is an unfavorable symptom. If it is necessary to intubate the patient, resuscitation measures should not be interrupted for more than 30 seconds.

lechiserdce.ru

CPR in children

Resuscitation guidelines published by the European Resuscitation Council

Section 6. Resuscitation measures in children

Introduction

Background

The European Resuscitation Council (ERC) has previously issued Guidelines for Pediatric Life Support (PLS) in 1994, 1998 and 2000. Latest edition was created based on the final recommendations of the International Scientific Consensus issued by the American Heart Association in collaboration with the International Consensus Committee on Resuscitation (ILCOR); it included separate recommendations for cardiopulmonary resuscitation and emergency cardiac care, published in “Guide 2000” in August 2000. According to the same principle in 2004-2005. The final conclusions and practical recommendations of the Consensus Meeting were initially published simultaneously in all leading European publications on this topic in November 2005. The Working Group of the Pediatric Section (PLS) of the European Council of Critical Care Medicine reviewed this document and related scientific publications and recommended changes to the pediatric section of the Guidelines. These changes are presented in this edition.

Changes made to this manual

The changes were made in response to new scientific evidence and the need to simplify practices as much as possible to facilitate learning and maintenance of the practices. As in previous editions, there is a paucity of evidence from direct pediatric practice and some conclusions are drawn from animal modeling and extrapolation from adult patients. This guide focuses on simplifying techniques, recognizing that many children do not receive any resuscitation care for fear of harm. This fear is supported by the idea that resuscitation techniques in children are different from those used in adult practice. Based on this, many studies have clarified the issue of the possibility of using the same resuscitation methods in adults and children. Resuscitation assistance When provided at the scene by witnesses to the incident, it significantly increases survival and in modeling situations in young animals it is clearly shown that performing chest compressions or ventilatory breathing alone can be much more beneficial than doing nothing at all. Thus, survival can be increased by training bystanders to use resuscitation techniques, even if they are not familiar with pediatric resuscitation. Of course, there are differences in the treatment of predominantly cardiac in origin in adults and asphyxial in children acute pulmonary heart failure, therefore a separate pediatric algorithm is recommended for use in professional practice.

Compression-ventilation ratio

ILCOR recommends different compression-ventilation ratios depending on the number of participants in care. For non-professionals trained in only one technique, a ratio of 30 compressions to 2 ventilating exhalations is suitable, that is, the use of resuscitation algorithms for adult patients. Professional rescuers, two or more in a group, should use a different ratio - (15:2), as the most rational for children, obtained as a result of experiments with animals and mannequins. Medical professionals should be familiar with the peculiarities of pediatric resuscitation techniques. A ratio of 15:2 has been found to be optimal in animal, mannequin and mathematical model studies, with various ratios ranging from 5:1 to 15:2; the results were not displayed optimal ratio compression-ventilation, but showed that the 5:1 ratio is the least suitable for use. Because the need for different resuscitation techniques for children over and under 8 years of age has not been demonstrated, the ratio of 15:2 was chosen as the most logical ratio for professional rescue teams. For non-professional rescuers, regardless of the number of participants in providing assistance, it is recommended to adhere to the ratio of 30:2, which is especially important if there is only one rescuer and it is difficult for him to move from compression to ventilation.

Dependence on the child's age

The use of different resuscitation techniques for children over and under 8 years of age, as recommended by previous guidelines, has been deemed inappropriate, and restrictions on the use of automated external defibrillators (AEDs) have also been lifted. The reason for different resuscitation tactics in adults and children is etiological; For adults, primary cardiac arrest is typical, while in children it is usually secondary. A sign of the need to switch to resuscitation tactics used in adults is the onset of puberty, which is the most logical indicator of the end of the physiological period of childhood. This approach facilitates recognition, since age at the start of resuscitation is often unknown. At the same time, it is obvious that there is no need to formally determine the signs of puberty; if a rescuer sees a child in front of him, he needs to use pediatric resuscitation techniques. If pediatric resuscitation tactics are used in early adolescence, this will not cause harm to health, since studies have proven the common etiology of pulmonary heart failure in childhood and early adolescence. Children's age should be considered from one year to puberty; Ages up to 1 year should be considered infantile, and at this age the physiology is significantly different.

Chest compression technique

Recommendations for choosing an area on the chest to apply compression force have been simplified for of different ages. It is considered advisable to use the same anatomical landmarks in infants (children under one year old) as for older children. The reason for this is that following previous guidelines sometimes resulted in compression in the upper abdominal area. The technique for performing compression in infants remains the same - using two fingers if there is only one rescuer; and the use of the thumbs of both hands with a chest girth if there are two or more rescuers, but for older children there is no division into one- and two-handed techniques. In all cases, it is necessary to achieve a sufficient depth of compression with minimal interruptions.

Automatic external defibrillators

Publication data since the 2000 Guidelines have reported safe and successful use of AEDs in children under 8 years of age. Moreover, recent evidence shows that AEDs accurately detect arrhythmias in children and the likelihood of mistimed or incorrect shock delivery is very low. Therefore, the use of AEDs in all children over 1 year of age is now recommended. But any device that suggests the possibility of use for arrhythmias in children must undergo appropriate testing. Many manufacturers today equip devices with pediatric electrodes and programs that involve adjusting the discharge in the range of 50-75 J. Such devices are recommended for use in children from 1 to 8 years. In the absence of a device equipped with a similar system or the ability to manually configure it, for children over one year old it is possible to use an unmodified model for adults. For children under 1 year of age, the use of AEDs remains questionable because there is insufficient data either for or against such use.

Manual (non-automatic) defibrillators

The 2005 Consensus Conference recommended prompt defibrillation in children with ventricular fibrillation (VF) or pulseless ventricular tachycardia (PT). Adult life support (ALS) involves delivering a single shock and immediately resuming CPR without detecting a pulse or returning the heart rate (see Section 3). When using a monophasic discharge, it is recommended to use a first discharge of higher power than previously recommended - 360 rather than 200 J. (See Section 3). The ideal shock rate for children is unknown, but animal modeling and a small amount of pediatric data suggest that rates greater than 4 J kg-1 give good effect defibrillation with minor side effects. Bipolar discharges are at least more effective and less disruptive to myocardial function. To simplify the procedure technique and in accordance with recommendations for adult patients, we recommend the use of one defibrillating discharge (mono- or biphasic) with a dose not exceeding 4 J/kg in children.

Algorithm of actions for airway obstruction by a foreign body

The algorithm of actions for foreign body airway obstruction in children (FBAO) has been simplified as much as possible and is as close as possible to the algorithm used in adult patients. The changes made are discussed in detail at the end of this section.

6a Basic resuscitation in children.

Sequencing

Rescuers trained in basic adult resuscitation and unfamiliar with pediatric resuscitation techniques can use adult resuscitation techniques with the difference that they must first give 5 rescue breaths before starting CPR (see Figure 6.1).
Rice. 6.1 Algorithm of basic resuscitation measures in pediatrics. All medical workers should know this UNRESPONSIVE? - Check for consciousness (responsive or not?) Shout for help - Call for help Open airway - clear the airways NOT BREATHING NORMALLY? - Check your breathing (is it adequate or not?) 5 rescue breaths - 5 artificial breaths STILL UNRESPONSIVE? (no signs of a circulation) - Still no consciousness (no signs of circulation) 15 chest compressions - 15 chest compressions 2 rescue breaths - 2 artificial breaths After 1 minute call resuscitation team then continue CPR - Call the resuscitation team in a minute, then continue resuscitation Sequence of actions recommended for pediatric resuscitation professionals: 1 Ensure the safety of the child and others

Gently stir the child and ask loudly: “Are you okay?”

Do not handle your child if you suspect a neck injury.

3a If the child reacts with speech or movement

Leave the child in the position in which you found him (to avoid aggravating the damage)

Re-evaluate his condition periodically

3b If the child does not respond, then

call loudly for help;

open his airway by tilting his head back and lifting his chin as follows:

• first, without changing the child’s position, place your palm on his forehead and tilt his head back;

  At the same time, place your finger in the chin fossa and lift your jaw. Do not press on the soft tissue below the chin, as this may close the air passages;

  if the air passages cannot be opened, use the jaw extrusion method. Taking two fingers of both hands by the corners of the lower jaw, lift it;

  Both techniques are made easier by carefully placing the child on his back.

If a neck injury is suspected, open the airway only by withdrawing the mandible. If this is not enough, very gradually, with measured movements, tilt your head back until the airways open.

4 While ensuring the airway is clear, listen and try to feel the baby's breathing by bringing your head close to him and watching the movement of his chest.

Look closely to see if the chest moves.

Listen to see if the child is breathing.

Try to feel his breath on your cheek.

Assess visually, auditorily and tactilely for 10 seconds to assess breathing status

5a If the child is breathing normally

Place baby in a stable side position (see below)

Continue checking for breathing

5b If the child is not breathing, or his breathing is agonal (slow and irregular)

carefully remove anything that interferes with breathing;

give five initial rescue breaths;

During these procedures, monitor for possible coughing or gagging. This will determine your further actions, their description is given below.

Resuscitation breathing for a child over 1 year of age is performed as shown in Fig. 6.2.

Tilt your head back and lift your chin up.

Pinch the soft tissues of the nose with a large and index fingers hand lying on the child's forehead.

Open his mouth slightly, leaving his chin raised.

Inhale and, wrapping your lips around the child’s mouth, make sure the contact is tight.

Exhale evenly into the airways for 1-1.5 seconds, observing the response movement of the chest.

Leaving the baby's head in a tilted position, watch the lowering of his chest as he exhales.

Inhale again and repeat in the same sequence up to 5 times. Monitor the effectiveness of sufficient movement of the child's chest - as during normal breathing.

Rice. 6.2 Mouth-to-mouth ventilation in a child older than one year.

Resuscitation breathing in an infant is carried out as shown in Fig. 6.3.

Make sure your head is in a neutral position and your chin is lifted.

Inhale and cover the baby's mouth and nasal passages with your lips, making sure there is a tight seal. If the child is large enough and it is impossible to cover the mouth and nasal passages at the same time, you can use mouth-to-mouth or mouth-to-nose breathing only (while keeping the child's lips closed).

Exhale evenly into the airway for 1-1.5 seconds, noticing the subsequent movement of his chest.

Leaving the baby's head in a tilted position, evaluate the movement of his chest as he exhales.

Take another breath and repeat ventilation in the same sequence up to 5 times.

Rice. 6.3 Mouth-to-mouth and nose ventilation in a child up to one year old.

If the required breathing efficiency is not achieved, airway obstruction may occur.

Open your baby's mouth and remove anything that may be obstructing his breathing. Don't do blind cleansing.

Make sure that the head is tilted back and the chin is raised, without hyperextension of the head.

If tilting your head back and lifting your jaw does not open your airway, try moving your jaw beyond its corners.

Make five attempts at ventilating breathing. If they are ineffective, move on to chest compressions.

If you are a professional, determine your pulse, but do not spend more than 10 seconds on it.

If the child is older than 1 year, determine the carotid pulsations. If the child is an infant, check the radial pulse above the elbow.

7a If within 10 seconds you were able to clearly identify signs of blood circulation

Continue CPR as long as necessary until the child is breathing adequately on his own.

Turn the child onto his side (in the recovery position) if he is still unconscious

Constantly re-evaluate the child's condition

7b If there are no signs of blood circulation, or the pulse is not detected, or it is too sluggish and less than 60 beats/min, -1 weak filling, or is not determined reliably

start chest compressions

combine chest compressions with ventilatory breathing.

Chest compression is carried out as follows: pressure is applied to the lower third of the sternum. To avoid compression of the upper abdomen, determine the position of the xiphoid process at the point of convergence of the lower ribs. The pressure point is located one finger splint above it; the compression should be deep enough - approximately a third of the thickness of the chest. Start pressing at a rate of about 100/min-1. After 15 compressions, tilt the child's head back, lift the chin and take 2 fairly effective exhalations. Continue compression and breathing at a ratio of 15:2, or if you are alone, 30:2, especially if the compression rate is 100/min, the actual number of shocks produced will be less due to the breaks in breathing. The optimal compression technique for infants and children is slightly different. In infants, the procedure is performed by pressing on the sternum with the tips of two fingers. (Fig. 6.4). If there are two or more rescuers, the girth technique is used. Place your thumbs on the lower third of the sternum (as above), with your fingertips pointing toward your baby's head. Wrap the fingers of both hands around the baby's chest so that the fingertips support his back. Press your thumbs into your sternum to about a third of the thickness of your ribcage.

Rice. 6.4 Chest compression in a child under one year old. To perform chest compressions on a child older than one year, place the heel of your hand on the lower third of his sternum. (Fig. 6.5 and 6.6). Raise your fingers so there is no pressure on the baby's ribs. Stand vertically over the baby's chest and, with your arms straight, apply compression to the lower third of the sternum to a depth of approximately one-third of the thickness of the chest. In adult children or when the rescuer has a small mass, this is easier to do by intertwining the fingers.

Rice. 6.5 Chest compression in a child under one year old.

Rice. 6.6 Chest compression in a child under one year old.

8 Continue resuscitation until

The child still has signs of life (spontaneous breathing, pulse, movement)

Until qualified help arrives

Until complete exhaustion sets in

When to Call for Help

If the child is unconscious, it is necessary to call for help as soon as possible.

If two people are involved in resuscitation, then one begins resuscitation, while the second goes to call for help.

If there is only one rescuer, it is necessary to perform resuscitation measures for one minute before going to call for help. To reduce interruptions in compression, you can take the baby or small child with you when calling for help.

There is only one case where you can immediately go for help without performing resuscitation for a minute - if someone saw that the child suddenly lost consciousness, and there was only one rescuer. In this case, acute heart failure is most likely arrhythmogenic, and the child needs urgent defibrillation. If you are alone, seek help immediately.

Recovery position

An unconscious child with a patent airway and spontaneous breathing should be placed in the recovery position. There are several options for such provisions, each with its own supporters. It is important to follow the following principles:

The baby's position should be as close to the lateral position as possible to allow fluid to drain from the mouth.

The situation must be stable. The baby needs to place a small pillow or folded blanket under his back.

Avoid any pressure on the chest to prevent shortness of breath.

It must be possible to safely turn onto your back and back onto your side, as there is always a possibility of spinal injury.

Access to the airway must be maintained.

The position used in adults can be used.

Low heart pressure in older people: what to do

Heart rate is normal in children

Primary cardiac arrest occurs much less frequently in children than in adults. Ventricular fibrillation accounts for less than 10% of all clinical deaths in children. Most often it is a consequence of congenital pathology.

The most common reason for CPR in children is trauma.

Cardiopulmonary resuscitation in children has certain features.

When carrying out mouth-to-mouth breathing, it is necessary to avoid excessively deep insufflations (that is, exhalation of the resuscitator). The indicator can be the volume of the excursion chest wall, which is labile in children and its movements are well controlled visually. Foreign bodies cause airway obstruction in children more often than in adults.

In the absence of spontaneous breathing in a child, after 2 artificial breaths, it is necessary to begin cardiac massage, since with apnea, cardiac output is usually inadequately low, and palpation of the pulse in the carotid artery in children is often difficult. It is recommended to palpate the pulse in the brachial artery.

It should be noted that the absence of a visible apical impulse and the impossibility of palpation do not yet indicate cardiac arrest.

If there is a pulse, but there is no spontaneous breathing, then the resuscitator should take approximately 20 breaths per minute until spontaneous breathing is restored or more modern methods Ventilation If there is no pulsation of the central arteries, cardiac massage is necessary.

Compression of the chest in a small child is performed with one hand, and the other is placed under the child’s back. In this case, the head should not be higher than the shoulders. The place of application of force in young children is Bottom part sternum. Compression is performed with 2 or 3 fingers. The amplitude of movement should be 1-2.5 cm, the frequency of compressions should be approximately 100 per minute. Just like with adults, you need to pause for ventilation. The ventilation-compression ratio is also 1:5. Approximately every 3 to 5 minutes, check for spontaneous heartbeats. Hardware compression is usually not used in children. It is not recommended to use an anti-shock suit in children.

If open heart massage in adults is considered more effective than closed one, then in children no such advantage of direct massage has been identified. Apparently, this is explained by the good compliance of the chest wall in children. Although in some cases, if indirect massage is ineffective, you should resort to direct massage. When drugs are administered into the central and peripheral veins, such a difference in the rate of onset of effect in children is not observed, but if possible, catheterization of the central vein should be performed. The onset of action of drugs administered intraosseously to children is comparable in time to intravenous administration. This route of administration can be used during cardiopulmonary resuscitation, although complications may occur (osteomyelitis, etc.). There is a risk of microfat pulmonary embolism with intraosseous injection, but this is not particularly important clinically. Endotracheal administration of fat-soluble drugs is also possible. It is difficult to recommend a dose due to the large variability in the rate of absorption of drugs from the tracheobronchial tree, although, apparently, the intravenous dose of adrenaline should be increased 10 times. The dose of other drugs should also be increased. The drug is injected deeply into the tracheobronchial tree through a catheter.

Intravenous fluid administration during cardiopulmonary resuscitation in children is more important than in adults, especially with severe hypovolemia (blood loss, dehydration). Children should not be given glucose solutions (even 5%) because large volumes of glucose-containing solutions lead to hyperglycemia and increased neurological deficits more quickly than in adults. If hypoglycemia is present, it is corrected with glucose solution.

Most effective drug in case of circulatory arrest, adrenaline is administered at a dose of 0.01 mg/kg (10 times more endotracheally). If there is no effect, re-administer after 3-5 minutes, increasing the dose by 2 times. In the absence of effective cardiac activity, intravenous infusion of adrenaline is continued at a rate of 20 mcg/kg per minute; when heart contractions resume, the dose is reduced. For hypoglycemia, drip infusions of 25% glucose solutions are necessary; bolus injections should be avoided, since even short-term hyperglycemia can negatively affect the neurological prognosis.

Defibrillation in children is used for the same indications (ventricular fibrillation, ventricular tachycardia with absence of pulse) as in adults. In young children, electrodes of slightly smaller diameter are used. The initial discharge energy should be 2 J/kg. If this value of discharge energy is insufficient, the attempt must be repeated with a discharge energy of 4 J/kg. The first 3 attempts should be made at short intervals. If there is no effect, hypoxemia, acidosis, hypothermia are corrected, adrenaline hydrochloride and lidocaine are administered.